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Data Collection (Forms) Library

Forms produced by the Wisconsin Department of Health Services are available electronically and/or for paper order. Review the "Available to Order" column below to ensure availability in paper format. If the document is available to order in a paper version, there will be a "Yes" with a link to ordering instructions.

When you are searching for a form, enter the number or a portion of the title in the search box below.

Assigned Number Title Division Language Release Date File Type Available to Order
F-26003H Notice of Privacy Practices - Treatment Facilities - HCC, Hmong DCTS Hmong 01/2022 PDF No
F-26003 Notice of Privacy Practices - Treatment Facilities - HCC DCTS English 01/2022 PDF No
F-26003 Notice of Privacy Practices - Treatment Facilities - HCC DCTS English 01/2022 Word No
F-26003H Notice of Privacy Practices - Treatment Facilities - HCC, Hmong DCTS Hmong 01/2022 Word No
F-02260 Temporary QUEST Card Issuance Checklist DMS English 01/2022 PDF No
F-02106 Adult Day Care Center - Applicant Compliance Statement DQA English 01/2022 Word No
F-02927 Nurse Aide Training Prohibition Waiver Request DQA 01/2022 HTML No
F-82064AH Background Information Disclosure (BID) Instructions, Hmong DQA Hmong 01/2022 PDF No
F-82064S Background Information Disclosure (BID), Spanish DQA Spanish 01/2022 PDF No
F-82064A Background Information Disclosure (BID) Instructions DQA English 01/2022 PDF No
F-82064 Background Information Disclosure (BID) DQA English 01/2022 PDF No
F-82064AS Background Information Disclosure (BID) Instructions, Spanish DQA Spanish 01/2022 PDF No
F-82064H Background Information Disclosure (BID), Hmong DQA Hmong 01/2022 PDF No
F-11237 Specialized Medical Vehicle Providers Affidavit DMS English 01/2022 Word No
F-11237 Specialized Medical Vehicle Providers Affidavit DMS English 01/2022 PDF No
F-02237 Pre-Hire Driving Record Review DES English 01/2022 Word No
F-02467 Children's Long-Term Support: Care Level Classification DMS English 01/2022 Word No
F-01952 Prior Authorization Drug Attachment for Cytokine and CAM Antagonist Drugs for DIRA, Giant Cell Arteritis, NOMID, and nr-axSpA DMS English 01/2022 Word No
F-01672A Prior Authorization/Preferred Drug List (PA/PDL) for Non-Preferred Stimulants, Instructions DMS English 01/2022 PDF No
F-01952A Prior Authorization Drug Attachment for Cytokine and CAM Antagonist Drugs for DIRA, Giant Cell Arteritis, NOMID, and nr-axSpA, Instructions DMS English 01/2022 PDF No
F-01952 Prior Authorization Drug Attachment for Cytokine and CAM Antagonist Drugs for DIRA, Giant Cell Arteritis, NOMID, and nr-axSpA DMS English 01/2022 PDF No
F-11077A Prior Authorization/Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), Instructions DMS English 01/2022 PDF No
F-00232 Instructions DMS English 12/2021 PDF No
F-00232SE Notice of Adverse Benefit Determination (Notice of Action), Serbo-Croatian DMS Serbian (Serbo-Croatian) 12/2021 Word No
F-00232AR Notice of Adverse Benefit Determination (Notice of Action), Arabic DMS Arabic 12/2021 Word No
F-00232H Notice of Adverse Benefit Determination (Notice of Action), Hmong DMS Hmong 12/2021 Word No
F-00232L Notice of Adverse Benefit Determination (Notice of Action), Laotian DMS Laotian 12/2021 Word No
F-00232 Notice of Adverse Benefit Determination (Notice of Action) DMS English 12/2021 Word No
F-00232SO Notice of Adverse Benefit Determination (Notice of Action), Somali DMS Somali 12/2021 Word No
F-00232S Notice of Adverse Benefit Determination (Notice of Action), Spanish DMS Spanish 12/2021 Word No
F-00232CM Notice of Adverse Benefit Determination (Notice of Action), Chinese Mandarin DMS Chinese Mandarin 12/2021 Word No
F-00367 Functional Eligibility Screen for Children's Long-Term Support Programs (PDF, 122 KB) DMS English 12/2021 PDF No
F-02923 WIIN Grant Child Care Provider Questionnaire DPH 12/2021 HTML No
F-01700 Exception-to-Policy Request DPH English 12/2021 Word No
F-02106B Adult Day Care Center: Certification Application Checklist DQA English 12/2021 Word No
F-10182S BadgerCare Plus Application Packet, Spanish DMS Spanish 12/2021 PDF No
F-10101PA Wisconsin Medicaid for the Elderly, Blind, or Disabled Application Packet, Pashto DMS Pashto 12/2021 PDF No
F-10101DA Wisconsin Medicaid for the Elderly, Blind, or Disabled Application Packet, Dari DMS Dari 12/2021 PDF No
F-10182H BadgerCare Plus Application Packet, Hmong DMS Hmong 12/2021 PDF No
F-10182PA BadgerCare Plus Application Packet, Pashto DMS Pashto 12/2021 PDF No
F-10182DA BadgerCare Plus Application Packet, Dari DMS Dari 12/2021 PDF No
F-10101S Wisconsin Medicaid for the Elderly, Blind, or Disabled Application Packet, Spanish DMS Spanish 12/2021 PDF No
F-10182 BadgerCare Plus Application Packet DMS English 12/2021 PDF Yes
F-10101 Wisconsin Medicaid for the Elderly, Blind, or Disabled Application Packet DMS English 12/2021 PDF Yes
F-10101H Wisconsin Medicaid for the Elderly, Blind, or Disabled Application Packet, Hmong DMS Hmong 12/2021 PDF No
F-02111 Assisted Living - Fit and Qualified Application for Community-Based Residential Facilities, Adult Family Homes and Adult Day Care Centers DQA English 12/2021 Word No
F-00165E Limited English Proficiency (LEP) Customer Data Analysis Chart OLC English 12/2021 Word No
F-00165A Recipient Contact Information OLC English 12/2021 Word No
F-01430A Prior Authorization Drug Attachment for Xyrem and Xywav, Instructions DMS English 12/2021 PDF No
F-00165D Customer Service Population Analysis (CSPA) Data Chart OLC English 12/2021 Word No
Last revised July 18, 2023